Clinical Policy: Gonioscopy Reference Number: OC.UM.CP.0031 Coding Implications Last Review Date: 05/2020 Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description Gonioscopy involves using a concave contact lens in conjunction with oblique mirrors to view the iridocorneal angle. This policy describes the medical necessity requirements for gonioscopy.

Policy/Criteria I. It is the policy of health plans affiliated with Envolve Vision, Inc.® that gonioscopy is medically necessary for the following indications: A. ; B. Glaucoma suspect; C. Ocular trauma; D. Hyphema; E. Hypotony; F. Occlusive disorders; G. Diabetic retinopathy; H. Rubeosis; I. Intraocular foreign body; or J. Subluxated or dislocated lens.

Background The angle of the anterior chamber of the is examined in a gonioscopy to assess for angle closure glaucoma, neovascularization, or other injury or disease process in the anterior chamber. Since the 's curvature creates internal reflection when the anterior angle structures are viewed directly, a gonioscopic lens is used to observe the angle. Corneal integrity is first determined using fluorescein. The patient is given anesthesia, the goniolens is prepared, and the physician places it on the patient's cornea. The lens puts a concave surface against the cornea, eliminating its refracting surface and allowing the angle to be observed with oblique mirrors. With the illumination lamp and microscope set and the beam oriented parallel to the axis of the mirror, the gonioscopy is accomplished and the angle of the anterior chamber of the eye is examined. The lens is removed, the eye is irrigated, and the cornea is checked again.

Gonioscopy of both should be performed on all patients in whom angle closure is suspected to evaluate the angle anatomy, appositional closure, and presence of peripheral anterior (PAS). Compression (indentation) gonioscopy with a four-mirror or similar lens is particularly helpful to determine if visible appositional closure is actually permanent, synechial closure and, if so, for the extent of such PAS.

Gonioscopy should be performed in a dark room with a bright, short (approximately 1 mm in length) beam that does not pass through the pupil to avoid inducing pupillary constriction, which can widen the angle. Gonioscopic visualization of the angle may be impaired secondary to

Page 1 of 22 CLINICAL POLICY Gonioscopy corneal edema in the setting of acute angle-closure glaucoma. Topical glycerin may be used to clear the cornea to obtain a better view.

The diagnosis of primary open angle glaucoma requires careful evaluation of the anterior chamber angle to exclude angle closure or secondary causes of (IOP) elevation, such as angle recession, pigment dispersion, peripheral anterior synechiae, angle neovascularization, and inflammatory precipitates.

Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2018, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

ICD-10-CM Diagnosis Codes that Support Coverage Criteria + Indicates a code requiring an additional character ICD-10-CM Description Code E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

Page 2 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye

Page 3 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

Page 4 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

Page 5 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

Page 6 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

Page 7 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

Page 8 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

Page 9 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

Page 10 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

Page 11 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

Page 12 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral H20.011 Primary iridocyclitis right eye H20.012 Primary iridocyclitis left eye H20.013 Primary iridocyclitis bilateral H20.021 Recurrent acute iridocyclitis right eye H20.022 Recurrent acute iridocyclitis left eye H20.023 Recurrent acute iridocyclitis bilateral H20.031 Secondary infectious iridocyclitis right eye H20.032 Secondary infectious iridocyclitis left eye H20.033 Secondary infectious iridocyclitis bilateral H20.041 Secondary noninfectious iridocyclitis right eye H20.042 Secondary noninfectious iridocyclitis left eye H20.043 Secondary noninfectious iridocyclitis bilateral H20.051 Hypopyon right eye H20.052 Hypopyon left eye H20.053 Hypopyon bilateral H20.11 Chronic iridocyclitis right eye H20.12 Chronic iridocyclitis left eye H20.13 Chronic iridocyclitis bilateral H20.21 Lens-induced iridocyclitis right eye H20.22 Lens-induced iridocyclitis left eye H20.23 Lens-induced iridocyclitis bilateral H20.811 Fuchs' heterochromic cyclitis right eye H20.812 Fuchs' heterochromic cyclitis left eye H20.813 Fuchs' heterochromic cyclitis bilateral H20.821 Vogt-Koyanagi syndrome right eye H20.822 Vogt-Koyanagi syndrome left eye H20.823 Vogt-Koyanagi syndrome bilateral H21.01 Hyphema right eye H21.02 Hyphema left eye H21.03 Hyphema bilateral H21.1X1 Other vascular disorders of iris and ciliary body right eye

Page 13 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code H21.1X2 Other vascular disorders of iris and ciliary body left eye H21.1X3 Other vascular disorders of iris and ciliary body bilateral H21.211 Degeneration of chamber angle right eye H21.212 Degeneration of chamber angle left eye H21.213 Degeneration of chamber angle bilateral H21.221 Degeneration of ciliary body right eye H21.222 Degeneration of ciliary body left eye H21.223 Degeneration of ciliary body bilateral H21.231 Degeneration of iris (pigmentary) right eye H21.232 Degeneration of iris (pigmentary) left eye H21.233 Degeneration of iris (pigmentary) bilateral H21.241 Degeneration of pupillary margin right eye H21.242 Degeneration of pupillary margin left eye H21.243 Degeneration of pupillary margin bilateral H21.251 Iridoschisis right eye H21.252 Iridoschisis left eye H21.253 Iridoschisis bilateral H21.261 Iris atrophy (essential) (progressive) right eye H21.262 Iris atrophy (essential) (progressive) left eye H21.263 Iris atrophy (essential) (progressive) bilateral H21.271 Miotic pupillary cyst right eye H21.272 Miotic pupillary cyst left eye H21.273 Miotic pupillary cyst bilateral H23.531 Iridodialysis, right eye H23.532 Iridodialysis, left eye H23.533 Iridodialysis, bilateral H27.01 Aphakia right eye H27.02 Aphakia left eye H27.03 Aphakia bilateral H27.111 Subluxation of lens right eye H27.112 Subluxation of lens left eye H27.113 Subluxation of lens bilateral H27.121 Anterior dislocation of lens right eye H27.122 Anterior dislocation of lens left eye H27.123 Anterior dislocation of lens bilateral H27.131 Posterior dislocation of lens right eye H27.132 Posterior dislocation of lens left eye H27.133 Posterior dislocation of lens bilateral H34.01 Transient retinal artery occlusion, right eye H34.02 Transient retinal artery occlusion, left eye H34.03 Transient retinal artery occlusion, bilateral H34.11 Central retinal artery occlusion, right eye H34.12 Central retinal artery occlusion, left eye

Page 14 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code H34.13 Central retinal artery occlusion, bilateral H34.211 Partial retinal artery occlusion, right eye H34.212 Partial retinal artery occlusion, left eye H34.213 Partial retinal artery occlusion, bilateral H34.231 Retinal artery branch occlusion, right eye H34.232 Retinal artery branch occlusion, left eye H34.233 Retinal artery branch occlusion, bilateral H34.8110 Central retinal vein occlusion, right eye, with macular edema H34.8111 Central retinal vein occlusion, right eye, with retinal neovascularization H34.8112 Central retinal vein occlusion, right eye, stable H34.8120 Central retinal vein occlusion, left eye, with macular edema H34.8121 Central retinal vein occlusion, left eye with retinal neovascularization H34.8122 Central retinal vein occlusion, left eye, stable H34.8130 Central retinal vein occlusion, bilateral, with macular edema H34.8131 Central retinal vein occlusion, bilateral, with retinal neovascularization H34.8132 Central retinal vein occlusion, bilateral, stable H34.821 Venous engorgement, right eye H34.822 Venous engorgement, left eye H34.823 Venous engorgement, bilateral H34.8310 Tributary (branch) retinal vein occlusion, right eye, with macular edema H34.8311 Tributary (branch) retinal vein occlusion, right eye, with retinal neovascularization H34.8312 Tributary (branch) retinal vein occlusion, right eye, stable H34.8320 Tributary (branch) retinal vein occlusion, left eye, with macular edema H34.8321 Tributary (branch) retinal vein occlusion, left eye, with retinal neovascularization H34.8322 Tributary (branch) retinal vein occlusion, left eye, stable H34.8330 Tributary (branch) retinal vein occlusion, bilateral, with macular edema H34.8331 Tributary (branch) retinal vein occlusion, bilateral, with retinal neovascularization H34.8332 Tributary (branch) retinal vein occlusion, bilateral, stable H35.011 Changes in retinal vascular appearance, right eye H35.012 Changes in retinal vascular appearance, left eye H35.013 Changes in retinal vascular appearance, bilateral H35.021 Exudative retinopathy, right eye H35.022 Exudative retinopathy, left eye H35.023 Exudative retinopathy, bilateral H35.031 Hypertensive retinopathy, right eye H35.032 Hypertensive retinopathy, left eye H35.033 Hypertensive retinopathy, bilateral H35.041 Retinal micro-aneurysms, unspecified, right eye H35.042 Retinal micro-aneurysms, unspecified, left eye H35.043 Retinal micro-aneurysms, unspecified, bilateral

Page 15 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code H35.051 Retinal neovascularization, unspecified, right eye H35.052 Retinal neovascularization, unspecified, left eye H35.053 Retinal neovascularization, unspecified, bilateral H35.061 Retinal vasculitis, right eye H35.062 Retinal vasculitis, left eye H35.063 Retinal vasculitis, bilateral H35.071 Retinal telangiectasis, right eye H35.072 Retinal telangiectasis, left eye H35.073 Retinal telangiectasis, bilateral H35.09 Other intraretinal microvascular abnormalities H40.011 Open angle with borderline findings, low risk, right eye H40.012 Open angle with borderline findings, low risk, left eye H40.013 Open angle with borderline findings, low risk, bilateral H40.021 Open angle with borderline findings, high risk, right eye H40.022 Open angle with borderline findings, high risk, left eye H40.023 Open angle with borderline findings, high risk, bilateral H40.031 Anatomical narrow angle, right eye H40.032 Anatomical narrow angle, left eye H40.033 Anatomical narrow angle, bilateral H40.041 Steroid responder, right eye H40.042 Steroid responder, left eye H40.043 Steroid responder, bilateral H40.051 Ocular hypertension, right eye H40.052 Ocular hypertension, left eye H40.053 Ocular hypertension, bilateral H40.061 Primary angle closure without glaucoma damage, right eye H40.062 Primary angle closure without glaucoma damage, left eye H40.063 Primary angle closure without glaucoma damage, bilateral H40.1111 Primary open-angle glaucoma, right eye, mild stage H40.1112 Primary open-angle glaucoma, right eye, moderate stage H40.1113 Primary open-angle glaucoma, right eye, severe stage H40.1121 Primary open-angle glaucoma, left eye, mild stage H40.1122 Primary open-angle glaucoma, left eye, moderate stage H40.1123 Primary open-angle glaucoma, left eye, severe stage H40.1131 Primary open-angle glaucoma, bilateral, mild stage H40.1132 Primary open-angle glaucoma, bilateral, moderate stage H40.1133 Primary open-angle glaucoma, bilateral, severe stage H40.1211 Low-tension glaucoma, right eye, mild stage H40.1212 Low-tension glaucoma, right eye, moderate stage H40.1213 Low-tension glaucoma, right eye, severe stage H40.1221 Low-tension glaucoma, left eye, mild stage H40.1222 Low-tension glaucoma, left eye, moderate stage

Page 16 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code H40.1223 Low-tension glaucoma, left eye, severe stage H40.1231 Low-tension glaucoma, bilateral, mild stage H40.1232 Low-tension glaucoma, bilateral, moderate stage H40.1233 Low-tension glaucoma, bilateral, severe stage H40.1311 Pigmentary glaucoma, right eye, mild stage H40.1312 Pigmentary glaucoma, right eye, moderate stage H40.1313 Pigmentary glaucoma, right eye, severe stage H40.1321 Pigmentary glaucoma, left eye, mild stage H40.1322 Pigmentary glaucoma, left eye, moderate stage H40.1323 Pigmentary glaucoma, left eye, severe stage H40.1331 Pigmentary glaucoma, bilateral, mild stage H40.1332 Pigmentary glaucoma, bilateral, moderate stage H40.1333 Pigmentary glaucoma, bilateral, severe stage H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage H40.151 Residual stage of open-angle glaucoma, right eye H40.152 Residual stage of open-angle glaucoma, left eye H40.153 Residual stage of open-angle glaucoma, bilateral H40.211 Acute angle-closure glaucoma, right eye H40.212 Acute angle-closure glaucoma, left eye H40.213 Acute angle-closure glaucoma, bilateral H40.2211 Chronic angle-closure glaucoma, right eye, mild stage H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage H40.2213 Chronic angle-closure glaucoma, right eye, severe stage H40.2221 Chronic angle-closure glaucoma, left eye, mild stage H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage H40.2223 Chronic angle-closure glaucoma, left eye, severe stage H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage H40.231 Intermittent angle-closure glaucoma, right eye H40.232 Intermittent angle-closure glaucoma, left eye

Page 17 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code H40.233 Intermittent angle-closure glaucoma, bilateral H40.241 Residual stage of angle-closure glaucoma, right eye H40.242 Residual stage of angle-closure glaucoma, left eye H40.243 Residual stage of angle-closure glaucoma, bilateral H40.31X1 Glaucoma secondary to eye trauma, right eye, mild stage H40.31X2 Glaucoma secondary to eye trauma, right eye, moderate stage H40.31X3 Glaucoma secondary to eye trauma, right eye, severe stage H40.32X1 Glaucoma secondary to eye trauma, left eye, mild stage H40.32X2 Glaucoma secondary to eye trauma, left eye, moderate stage H40.32X3 Glaucoma secondary to eye trauma, left eye, severe stage H40.33X1 Glaucoma secondary to eye trauma, bilateral, mild stage H40.33X2 Glaucoma secondary to eye trauma, bilateral, moderate stage H40.33X3 Glaucoma secondary to eye trauma, bilateral, severe stage H40.41X1 Glaucoma secondary to eye inflammation, right eye, mild stage H40.41X2 Glaucoma secondary to eye inflammation, right eye moderate stage H40.41X3 Glaucoma secondary to eye inflammation, right eye, severe stage H40.42X1 Glaucoma secondary to eye inflammation left eye mild stage H40.42X2 Glaucoma secondary to eye inflammation, left eye, moderate stage H40.42X3 Glaucoma secondary to eye inflammation left eye severe stage H40.43X1 Glaucoma secondary to eye inflammation, bilateral, mild stage H40.43X2 Glaucoma secondary to eye inflammation bilateral moderate stage H40.43X3 Glaucoma secondary to eye inflammation, bilateral, severe stage H40.51X1 Glaucoma secondary to other eye disorders, right eye, mild stage H40.51X2 Glaucoma secondary to other eye disorders, right eye, moderate stage H40.51X3 Glaucoma secondary to other eye disorders, right eye, severe stage H40.52X1 Glaucoma secondary to other eye disorders, left eye, mild stage H40.52X2 Glaucoma secondary to other eye disorders, left eye, moderate stage H40.52X3 Glaucoma secondary to other eye disorders, left eye, severe stage H40.53X1 Glaucoma secondary to other eye disorders, bilateral, mild stage H40.53X2 Glaucoma secondary to other eye disorders, bilateral, moderate stage H40.53X3 Glaucoma secondary to other eye disorders, bilateral, severe stage H40.61X1 Glaucoma secondary to drugs, right eye, mild stage H40.61X2 Glaucoma secondary to drugs, right eye, moderate stage H40.61X3 Glaucoma secondary to drugs, right eye, severe stage H40.62X1 Glaucoma secondary to drugs, left eye, mild stage H40.62X2 Glaucoma secondary to drugs, left eye, moderate stage H40.62X3 Glaucoma secondary to drugs, left eye, severe stage H40.63X1 Glaucoma secondary to drugs, bilateral, mild stage H40.63X2 Glaucoma secondary to drugs, bilateral, moderate stage H40.63X3 Glaucoma secondary to drugs, bilateral, severe stage

Page 18 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code H40.811 Glaucoma with increased episcleral venous pressure, right eye H40.812 Glaucoma with increased episcleral venous pressure, left eye H40.813 Glaucoma with increased episcleral venous pressure, bilateral H40.821 Hypersecretion glaucoma, right eye H40.822 Hypersecretion glaucoma, left eye H40.823 Hypersecretion glaucoma, bilateral H40.831 Aqueous misdirection, right eye H40.832 Aqueous misdirection, left eye H40.833 Aqueous misdirection, bilateral H44.411 Flat anterior chamber hypotony of right eye H44.412 Flat anterior chamber hypotony of left eye H44.413 Flat anterior chamber hypotony bilateral H44.421 Hypotony of right eye due to ocular fistula H44.422 Hypotony of left eye due to ocular fistula H44.423 Hypotony of bilateral eyes due to ocular fistula H44.431 Hypotony of right eye due to other ocular disorders H44.432 Hypotony of left eye due to other ocular disorders H44.433 Hypotony of eye due to other ocular disorders, bilateral H44.441 Primary hypotony of right eye H44.442 Primary hypotony of left eye H44.443 Primary hypotony bilateral H44.601 Unspecified retained (old) intraocular foreign body, magnetic, right eye H44.602 Unspecified retained (old) intraocular foreign body, magnetic, left eye H44.603 Unspecified retained (old) intraocular foreign body, magnetic bilateral H44.701 Unspecified retained (old) intraocular foreign body nonmagnetic right eye H44.702 Unspecified retained (old) intraocular foreign body nonmagnetic left eye H44.703 Unspecified retained (old) intraocular foreign body nonmagnetic bilateral Q15.0 Congenital glaucoma S05.11XA Contusion of eyeball and orbital tissues, right eye, initial encounter S05.11XD Contusion of eyeball and orbital tissues, right eye, subsequent encounter S05.11XS Contusion of eyeball and orbital tissues, right eye, sequela S05.12XA Contusion of eyeball and orbital tissues, left eye, initial encounter S05.12XD Contusion of eyeball and orbital tissues, left eye, subsequent encounter S05.12XS Contusion of eyeball and orbital tissues, sequela S05.51XA Penetrating wound with foreign body of right eyeball initial encounter S05.51XD Penetrating wound with foreign body of right eyeball subsequent encounter S05.51XS Penetrating wound with foreign body of right eyeball sequela S05.52XA Penetrating wound with foreign body of left eyeball initial encounter

Page 19 of 22 CLINICAL POLICY Gonioscopy ICD-10-CM Description Code S05.52XD Penetrating wound with foreign body of left eyeball subsequent encounter S05.52XS Penetrating wound with foreign body of left eyeball sequela S05.61XA Penetrating wound without foreign body of right eye initial encounter S05.61XD Penetrating wound without foreign body of right eye subsequent encounter S05.61XS Penetrating wound without foreign body of right eye sequela S05.62XA Penetrating wound without foreign body of left eye initial encounter S05.62XD Penetrating wound without foreign body of left eye subsequent encounter S05.62XS Penetrating wound without foreign body of left eye sequela

Reviews, Revisions, and Approvals Date Approval Date Original approval date 12/2019 12/2019 Converted to new template 05/2020 06/2020

References 1. “A History of Gonioscopy”, Alward, Wallace L.M., & Vision Science: January 2011 – Volume 88 – Issue 1 – pp 29-35 2. American Academy of Glaucoma Panel, Preferred Practice Pattern® Guidelines. Primary Open-Angle Glaucoma, San Francisco, CA: American Academy of Ophthalmology; 2015, www.aao.org/ppp 3. American Academy of Ophthalmology Glaucoma Panel, Preferred Practice Pattern® Guidelines. Primary Angle Closure, San Francisco, CA: American Academy of Ophthalmology; 2015, www.aao.org/ppp 4. Reimbursement Considerations for Gonioscopy, A Discussion of Coverage, Coding and Billing; Donna M. McCune, CCS-P, COE and Kevin J. Corcoran, COE, CPC, FNAO, Glaucoma Today, September/October 2008

Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Envolve Vision, Inc., or any of such health plan’s affiliates, as applicable.

Page 20 of 22 CLINICAL POLICY Gonioscopy The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.

Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

©2018 Envolve, Inc. All rights reserved. All materials are exclusively owned by Envolve and are protected by United States copyright law and international copyright law. No part of this

Page 21 of 22 CLINICAL POLICY Gonioscopy publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Envolve. You may not alter or remove any trademark, copyright or other notice contained herein.

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